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Kashkoush A, El-Abtah ME, Davison MA, Toth G, Moore N, Bain M. Repeat Flow Diversion for Retreatment of Incompletely Occluded Large Complex Symptomatic Cerebral Aneurysms: A Retrospective Case Series. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01027. [PMID: 38251895 DOI: 10.1227/ons.0000000000001056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 12/01/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Data regarding radiographic occlusion rates after repeat flow diversion after initial placement of a flow diverter (FD) in large intracranial aneurysms are limited. We report clinical and angiographic outcomes on 7 patients who required retreatment with overlapping FDs after initial flow diversion for large intracranial aneurysms. METHODS We performed a retrospective review of a prospectively maintained database of cerebrovascular procedures performed at our institution from 2017 to 2021. We identified patients who underwent retreatment with overlapping FDs for large (>10 mm) cerebral aneurysms after initial flow diversion. At last angiographic follow-up, occlusion grade was evaluated using the O'Kelly-Marotta (OKM) grading scale. RESULTS Seven patients (median age 57 years) with cerebral aneurysms requiring retreatment were identified. The most common aneurysm location was the ophthalmic internal carotid artery (n = 3) and basilar trunk (n = 3). There were 4 fusiform and 3 saccular aneurysms. The median aneurysm width was 18 mm; the median neck size for saccular aneurysms was 7 mm; and the median dome-to-neck ratio was 2.8. The median time to retreatment was 9 months, usually due to symptomatic mass effect. After retreatment, the median clinical follow-up was 36 months, MRI/magnetic resonance angiography follow-up was 15 months, and digital subtraction angiography follow-up was 14 months. Aneurysm occlusion at last angiographic follow-up was graded as OKM A (total filling, n = 1), B (subtotal filling, n = 2), C (early neck remnant, n = 3), and D (no filling, n = 0). All patients with symptomatic improvement were OKM C, whereas patients with worsened symptom burden were OKM A or B. Two patients required further open surgical management for definitive management of the aneurysm remnant. CONCLUSION Although most patients demonstrated a decrease in aneurysm remnant size, many had high-grade persistent filling (OKM grades A or B) in this subset of mostly large fusiform aneurysms. Larger studies with longer follow-up are warranted to optimize treatment strategies for atypical aneurysm remnants after repeat flow diversion.
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Affiliation(s)
- Ahmed Kashkoush
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mohamed E El-Abtah
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Mark A Davison
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Gabor Toth
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nina Moore
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mark Bain
- Department of Neurological Surgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Seshadri H, Saraf R, Barchha S. Radiological findings and endovascular management of internal carotid artery pseudoaneurysm in the setting of mucormycosis and COVID-19. BJR Case Rep 2024; 10:uaad006. [PMID: 38352267 PMCID: PMC10860580 DOI: 10.1093/bjrcr/uaad006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/21/2022] [Accepted: 11/14/2023] [Indexed: 02/16/2024] Open
Abstract
The coronavirus pandemic is now a public health emergency and has spread to nearly 206 countries across the globe. This novel disease has shaken the psycho-social, economic, and medical infrastructure of India. This has become even more challenging, considering the country's huge population. With the increase in the number of coronavirus disease (COVID) cases, our country has seen an unforeseen, unprecedented rise in a potential life and organ-threatening disease-mucormycosis. Mucormycosis is a deadly, extremely morbid, possibly life-threatening, and most feared complication of the coronavirus, caused by environmental molds belonging to the order Mucorales. Here, we report 2 cases of massive epistaxis due to internal carotid artery (ICA) pseudoaneurysm secondary to mucormycosis, post-COVID-19 pneumonia, which was managed by the endovascular route. To the best of our knowledge, there is very sparse literature available describing endovascular treatment of intracranial ICA pseudoaneurysm in a patient with COVID-induced mucormycosis.
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Affiliation(s)
| | - Rashmi Saraf
- Division of Interventional Neuroradiology, Department of Radiology, KEM Hospital, Mumbai 400012, India
| | - Satyam Barchha
- Department of Radiology, KEM Hospital, Mumbai 400012, India
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Gozal YM, Abou-Al-Shaar H, Alzhrani G, Taussky P, Couldwell WT. Complications of Endovascular and Open Aneurysm Surgery in the Era of Flow Diversion. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 130:85-94. [PMID: 37548727 DOI: 10.1007/978-3-030-12887-6_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
The techniques used for treatment of intracranial aneurysms have progressed dramatically over the decades. The introduction of modern endovascular techniques and the continued refinement of progressively less invasive neurosurgical approaches have contributed to steadily improving clinical outcomes. Moreover, innovations such as flow-diverting stents have achieved dramatic success and have gained rapid widespread adoption. Particularly in lesions for which the application of conventional treatment techniques is difficult, flow diversion technology has revolutionized aneurysm management. This review provides a discussion on the morbidity and mortality encountered in the treatment of intracranial aneurysms in the modern era. Common adverse events faced in the management of these lesions with open surgery and various endovascular techniques are highlighted.
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Affiliation(s)
- Yair M Gozal
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
- Mayfield Clinic, Cincinnati, OH, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gmaan Alzhrani
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
- Department of Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA.
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Guo H, Liu JF, Li CH, Wang JW, Li H, Gao BL. Effects of stent-assisted coiling in comparison with flow diversion on intracranial aneurysms. Front Neurol 2022; 13:937536. [PMID: 36425805 PMCID: PMC9679156 DOI: 10.3389/fneur.2022.937536] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 10/17/2022] [Indexed: 11/10/2022] Open
Abstract
Objective The aim of this study was to investigate the efficacy and complications of stent-assisted coiling in comparison with flow diversion for wide-necked intracranial aneurysms. Methods Patients with wide-necked intracranial aneurysms who were treated with stent-assisted coiling or flow diversion were respectively, enrolled into the stent-assisted coiling or flow diversion treatment group. The clinical and angiographic data were analyzed. Results A total of 61 patients with intracranial aneurysms underwent stent-assisted coiling, including 35 (57.4%) female and 26 (42.6%) male patients with 21 (34.4%) ruptured and 40 (65.6%) unruptured aneurysms. Also, 53 patients underwent deployment of flow-diverting devices, including 30 (56.6%) female and 23 (43.4%) male patients with 25 (47.2%) ruptured and 28 (52.8%) unruptured aneurysms. Stent-assisted coiling was performed successfully in 60 patients with 63 stents deployed, and immediate aneurysm occlusion was complete occlusion in 38 (62.3%) aneurysms, residual neck in 12 (19.7%), and residual aneurysm in 10 (16.4%). Procedure-related complications included in-stent thrombosis in three (4.9%) patients, coil protrusion in three (4.9%), and re-rupture of one (1.6%) aneurysm, with a total complication rate of 11.5%. In the flow diversion group, a pipeline embolization device alone was deployed in each of the 24 (45.3%) patients, adjunctive coiling combined with a pipeline device in 29 (54.7%), and double pipeline devices in each of the 6 (11.3%) patients. Immediately after treatment, complete occlusion was achieved in 3 (5.7%) patients with adjunctive coiling, residual neck in 3 (5.7%), and residual aneurysm in 47 (88.7%). Procedure-related complications included aneurysm rebleeding in one patient (1.9%). Clinical and angiographic follow-up was performed 13–49 months (median 29) after the procedure for 49 (80.3%) patients with stent-assisted coiling, with complete aneurysm occlusion in 27 (55.1%) aneurysms, residual neck in 3 (6.1%), residual aneurysm in 5 (10.2%), and recurrence in 14 (28.6%). Follow-up was performed for 14–37 (median 25) months in 45 (84.9%) patients with flow diversion treatment, with complete occlusion in 39 (86.7%) patients, residual neck in 5 (11.1%), residual aneurysm in 1 (2.2%), and no aneurysm recurrence. Conclusions Stent-assisted coiling comes with more complications but fewer permanent aneurysm occlusions than flow diverters, and flow diverters are superior to stent-assisted coiling in the treatment of wide-necked intracranial aneurysms, especially in the long-term effect.
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Li W, Xiao Z, Zhao K, Yang S, Zhang Y, Li B, Zhou Y, Ma Y, Chai E. Efficacy of pipeline embolization device vs. traditional coils in embolization of intracranial aneurysms: A systematic review and meta-analysis. Front Neurol 2022; 13:978602. [PMID: 36247783 PMCID: PMC9558282 DOI: 10.3389/fneur.2022.978602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/09/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionIn recent years, the Pipeline embolization device (PED) has been widely used in the embolization of intracranial aneurysms, but there are some inconsistent findings on whether its efficacy and safety are superior to those of traditional coils embolization (coils alone, stent-assisted coils and balloon-assisted coils). The purpose of this meta-analysis was to evaluate the safety and efficacy of PED in intracranial aneurysm embolization by comparing with traditional coils.MethodsWe systematically searched PubMed, Embase, Web of Science, and The Cochrane Library databases for randomized controlled trials and observational studies (case-control studies and cohort studies) comparing the efficacy of PED with traditional coils in intracranial aneurysm embolization published before April 1, 2022. The endpoints observed in this meta-analysis were procedure-related intracranial hemorrhage, procedure-related intracranial ischemia, other procedure-related complications (e.g., aneurysm rupture, neurological impairment, etc.), retreatment rate, complete occlusion (100%) of the aneurysm at the last follow-up, and favorable functional outcome (MRS ≤ 2).ResultsA total of 10 studies with a total of 1,400 patients (PED group: 576 and Traditional coils: 824) were included in this meta-analysis. A comprehensive analysis of the included literature showed that the PED group had a higher rate of complete aneurysm occlusion [OR = 2.62, 95% Cl (1.94, 3.55), p < 0.00001] and Lower re-treatment rate [OR = 0.20, 95% Cl (0.12, 0.34 p < 0.00001)] compared with the traditional coil embolization group at the last follow-up. In terms of procedure-related intracranial hemorrhage [OR = 3.04, 95% Cl (1.08, 8.57), p = 0.04] and other procedure-related complications [OR = 2.91, 95% Cl (1.48, 5.57), p = 0.002], the incidence of PED was higher than that of the traditional coil embolization group. Moreover, in terms of favorable functional outcome [OR = 0.4, 95% Cl (0.22, 0.71), p = 0.002] of patients at the last follow-up, the PED group was lower than the traditional coil embolization group. There was no statistically significant between the two groups in terms of surgery-related intracranial ischemia complications [OR = 0.88, 95% Cl (0.47, 1.64), p = 0.68].ConclusionPED had higher rates of complete aneurysm occlusion and lower rates of aneurysm retreatment compared with traditional coils, but traditional coils was superior to the PED group in terms of procedure-related intracranial hemorrhage complication and other procedure-related complications (aneurysm rupture, neurological impairment), and favorable functional outcome (mRS ≤ 2). This result still needs to be further confirmed by additional large-sample, multicenter, prospective randomized controlled trials.Systematic review registrationhttps://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022325673.
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Affiliation(s)
- Wei Li
- The First Clinical Medical College of Gansu University of Chinese Medicine, Lanzhou, China
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Zaixing Xiao
- The First Clinical Medical College of Gansu University of Chinese Medicine, Lanzhou, China
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Kaixuan Zhao
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Shijie Yang
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Yichuan Zhang
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Bin Li
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Yu Zhou
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
- The First Clinical Medical College of Lanzhou University, Lanzhou, China
| | - Yong Ma
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
| | - Erqing Chai
- Cerebrovascular Disease Center of Gansu Provincial People's Hospital, Lanzhou, China
- Key Laboratory of Cerebrovascular Diseases in Gansu Province, Lanzhou, China
- *Correspondence: Erqing Chai
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Wu Q, Li T, Jiang W, Hernesniemi JA, Li L, He Y. Conservative Therapy vs. Endovascular Approach for Intracranial Vertebrobasilar Artery Trunk Large Aneurysms: A Prospective Multicenter Cohort Study. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:9682507. [PMID: 35770042 PMCID: PMC9236797 DOI: 10.1155/2022/9682507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 05/30/2022] [Indexed: 11/30/2022]
Abstract
Background Intracranial vertebrobasilar trunk large (≥10 mm) aneurysms (IVBTLAs) are rare and challenging to manage. In this study, we describe the natural prognosis and evaluate the safety and efficacy of endovascular treatment of IVBTLAs compared with conservative therapy. Methods This prospective multicenter cohort study included patients with IVBTLAs, who chose either endovascular treatment (endovascular group) or conservative therapy (conservative group) after discussion with their doctors. The primary endpoint was the incidence of serious adverse events (SAEs) related to the target vessel, while secondary endpoints included target vessel-related mortality, major stroke, other serious adverse events, and aneurysm occlusion rate. Results In total, 258 patients were referred to our two centers for the management of vertebrobasilar aneurysms, and 69 patients had IVBTLAs. Among them, 51 patients underwent endovascular treatment, and 18 patients received conservative therapy. The incidence of target vessel-related SAEs was 15.7% (8/51) in the endovascular group and 44.4% (8/18) in the conservative group (P = 0.031). The target vessel-related mortality was 2.0% (1/51) in the endovascular group and 38.9% (7/18) in the conservative group (P < 0.001). The cumulative survival rates in the endovascular group and conservative group within 1-year, 3-year, and 5-year were 98.0% vs. 83.3%, P = 0.020; 98.0% vs. 66.7%, P = 0.001; and 98.0% vs. 35.6%, P < 0.001, respectively. Multivariate analysis revealed conservative therapy, giant aneurysm, and ischemic onset as risks factor for SAEs. Conclusions Compared with conservative treatment, endovascular treatment of the IVBTLAs may be associated with a lower incidence of SAEs, with higher 1-year, 3-year, and 5-year survival rates. Conservative therapy, giant aneurysm, and ischemic onset were associated with a high risk of SAEs.
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Affiliation(s)
- Qiaowei Wu
- Cerebrovascular Department of Interventional Center, Zhengzhou University People's Hospital, Henan University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, Henan, China
- Department of Neurosurgery, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Tianxiao Li
- Cerebrovascular Department of Interventional Center, Zhengzhou University People's Hospital, Henan University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Weijian Jiang
- Department of Vascular Neurosurgery, Chinese People's Liberation Army Rocket Force Characteristic Medical Center, Beijing, China
| | - Juha Antero Hernesniemi
- Cerebrovascular Department of Interventional Center, Zhengzhou University People's Hospital, Henan University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Li Li
- Cerebrovascular Department of Interventional Center, Zhengzhou University People's Hospital, Henan University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Yingkun He
- Cerebrovascular Department of Interventional Center, Zhengzhou University People's Hospital, Henan University People's Hospital and Henan Provincial People's Hospital, Zhengzhou, Henan, China
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Tanabe J, Nakahara I, Matsumoto S, Morioka J, Hasebe A, Watanabe S, Suyama K, Kuwahara K. Staged Hybrid Techniques With Straightforward Bypass Surgery Followed by Flow Diverter Deployment for Complex Recurrent Middle Cerebral Artery Aneurysms. Front Surg 2022; 9:824236. [PMID: 35187061 PMCID: PMC8848762 DOI: 10.3389/fsurg.2022.824236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/03/2022] [Indexed: 11/29/2022] Open
Abstract
Background Recurrent complex middle cerebral artery (MCA) aneurysms after combined clipping and endovascular surgery are challenging, and if conventional techniques are adapted, advanced surgical, endovascular, and a combination of both techniques are often required. For such complex aneurysms, safe and effective straightforward techniques for all neurovascular surgeons are warranted. We describe the details of staged hybrid techniques with straightforward bypass surgery followed by flow diverter deployment in a patient with complex MCA aneurysm. Illustrative Case A 69-year-old woman presented with left recurrent large MCA aneurysm enlargement 25 years after direct surgery and coil embolization for ruptured aneurysm. The recurrent MCA aneurysm had large and complex morphology and was adhering to the brain tissues. Therefore, it was unsuitable to treat such aneurysm with conventional surgical and endovascular techniques with a high risk of morbidity. We performed (1) M2 ligation following superficial temporal artery-M2 bypass and (2) flow diverter deployment assisted with coil packing in two sessions. Three months after the second session, the aneurysm was completely occluded with endothelialization of the neck. Angiographic findings revealed no recurrence 12 months after the treatment. Conclusions Staged hybrid techniques with straightforward bypass surgery followed by flow diverter deployment may be a safe and effective treatment for complex recurrent MCA aneurysms.
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Dalai S, Datla AV, Francis AA, Dannana NK, Parappil H. Endovascular Management of Mucormycotic Aneurysms of the Internal Carotid Artery in Post-COVID-19 Patients. Cureus 2021; 13:e20812. [PMID: 35141070 PMCID: PMC8799402 DOI: 10.7759/cureus.20812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2021] [Indexed: 12/19/2022] Open
Abstract
The repercussions of the coronavirus disease 2019 (COVID-19) are being felt throughout the world to this day. India is one such country ravaged by the second wave of the pandemic. Here, we report two cases of post-COVID-19 mucormycotic aneurysm of the internal carotid artery (ICA), which we believe are the first of their kind in the reported medical literature. A nasopharyngeal swab for reverse-transcriptase polymerase chain reaction of the severe acute respiratory syndrome coronavirus 2 was positive for both cases. After recovering from COVID-19, both patients developed signs and symptoms suggestive of mucormycosis, which were confirmed by a fungal smear. They were managed with liposomal amphotericin B (LAmB) and other adjunctive medicines. The first patient developed a massive bout of epistaxis during surgical debulking of his fungal mass. He underwent anterior nasal packing and emergency digital subtraction angiogram which revealed an aneurysm of the right ICA which was treated by coiling of the aneurysm and parent artery occlusion of the right ICA. The second patient had a history of post-COVID-19 mucormycosis which was managed by LAmB, surgical debulking, and posaconazole. He was not in regular follow-up and did not fully complete his antifungal therapy. Later, he presented with recurrent episodes of epistaxis followed by a massive bout of bleeding from both nostrils which upon evaluation revealed a thin-walled aneurysm of the left cavernous ICA. He was treated with flow diversion and coiling. Both patients responded well and the aneurysms were successfully excluded from the circulation. Their follow-ups were uneventful.
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Zhang Y, Wang C, Tian Z, Zhu W, Li W, Yang X, Liu J, Zhang Y. Risk factors for periprocedural ischemic stroke following endovascular treatment of intracranial aneurysms. Chin Neurosurg J 2021; 7:38. [PMID: 34425918 PMCID: PMC8381544 DOI: 10.1186/s41016-021-00255-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 08/02/2021] [Indexed: 11/29/2022] Open
Abstract
Background The aim of this study was to comprehensively evaluate the risk factors of periprocedural ischemic stroke associated with endovascular treatment of intracranial aneurysms using a real-world database. Methods From August 2016 to March 2017, 167 patients were enrolled. Univariate analysis and multivariate logistic regression analysis were used to examine the risk factors for periprocedural ischemic stroke. Results Among the 167 cases, periprocedural ischemic stroke occurred in 20 cases (11.98%). After univariate analysis, the ischemic group had a higher proportion of large (≥ 10 mm) aneurysms than the control group (45.0% vs. 23.1%, p = 0.036). The incidence of periprocedural ischemic stroke was higher in cases treated by flow diverter (21.6%) or stent-assisted coiling (11.8%) than in cases treated by coiling only (2.7%), and the differences were statistically significant (p = 0.043). After multivariate logistic regression analysis, treatment modality was the independent risk factor for periprocedural ischemic stroke. Compared with the coiling-only procedure, flow diverter therapy was associated with a significantly higher rate of periprocedural ischemic stroke (OR 9.931; 95% CI 1.174–84.038; p = 0.035). Conclusions Aneurysm size and treatment modality were associated with periprocedural ischemic stroke. Larger aneurysms were associated with increased risk of periprocedural ischemic stroke. Flow diverter therapy was associated with significantly more periprocedural ischemic stroke than the coiling procedure alone.
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Affiliation(s)
- Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Chao Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Zhongbin Tian
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Wei Zhu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Wenqiang Li
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China.
| | - Ying Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, No.119, South 4th Ring West Road, Fengtai District, Beijing, 100070, China.
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Xia JL, Li GL, Liu HE, Feng-Fei X, Gu XD. Flow-diverting device versus coil embolization for unruptured intracranial aneurysm: A meta-analysis. Medicine (Baltimore) 2021; 100:e26351. [PMID: 34128887 PMCID: PMC8213299 DOI: 10.1097/md.0000000000026351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 05/28/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Both coil embolization (CE) and flow-diverting device (FDD) placement are widely used for treatment of intracranial aneurysms (IAs). The aim of this meta-analysis is to compare the relative clinical safety and efficacy of FDD and CE for the treatment of unruptured IAs. METHODS The PubMed, Embase, and Cochrane Library databases were searched for relevant studies from the date of inception through April 2020. The primary endpoint for this meta-analysis was the 6-month rate of complete occlusion, while secondary endpoints included rates of retreatment, complications, and parental arterial patency. RESULTS This meta-analysis includes 8 studies, which included 839 total patients that underwent FDD and 2734 that underwent CE. FDD group exhibited a significantly higher pooled 6-month complete occlusion rate (P = .02). The subgroup analysis demonstrated that FDD treatment was associated with significantly higher pooled 6-month complete occlusion rates in patients with large or giant IAs (P < .00001), whereas no differences in 6-month complete occlusion rates were observed between the FDD and CE groups of patients with non-large/giant IAs (P = .83). The pooled retreatment (P = .16) and complication (P = .15) rates were comparable between 2 groups. The CE group exhibited significantly higher pooled parent artery patency rate (P = .01). The funnel plots did not reveal any evidence of publication bias. CONCLUSIONS FDDs can be used to effectively and safely treat large and giant IAs, achieving higher rates of complete occlusion than CE treatment. For non-large/giant IAs, we observed comparable efficacy between FDD and CE treatments.
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Affiliation(s)
| | | | | | - Xia Feng-Fei
- Department of Interventional Treatment, Binzhou People's Hospital, Binzhou, China
| | - Xin-Dong Gu
- Department of Interventional Treatment, Binzhou People's Hospital, Binzhou, China
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Li W, Zhu W, Sun X, Liu J, Wang Y, Wang K, Zhang Y, Yang X, Zhang Y. Retreatment With Flow Diverters and Coiling for Recurrent Aneurysms After Initial Endovascular Treatment: A Propensity Score-Matched Comparative Analysis. Front Neurol 2021; 12:625652. [PMID: 34149588 PMCID: PMC8209336 DOI: 10.3389/fneur.2021.625652] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 04/26/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Flow diverters and conventional coiling are established modalities for the retreatment of intracranial recurrent aneurysms after initial endovascular treatment. We aimed to compare the efficacy of these techniques. Methods: We retrospectively analyzed data for patients with recurrent aneurysms after initial endovascular treatment retreated in our center with either a pipeline embolization device (PED) or conventional coil embolization from January 2012 to July 2020. We performed 1:2 propensity score matching (PSM) using the nearest neighbor method. We controlled for: initial treatment strategy, aneurysm size, neck diameter, symptom presentation, history of aneurysm rupture, age, sex, fusiform-dissecting aneurysm, bifurcation aneurysm, and aneurysm location. The clinical and morphological factors of all patients at initial treatment and the angiographic and clinical results at the second treatment were collected and compared between the propensity-matched pairs. Results: A total of 105 intracranial aneurysms were identified; 18 patients (17.1%) were treated with a PED, and 87 (82.9%) were treated via conventional coil embolization. PSM resulted in 12 matched pairs (12 patients in the PED group and 24 in the coiling group). There was no significant difference of ischemic and hemorrhagic complications between the groups, the obliteration rate of branches covered by stent, or modified Rankin Scale scores at the last clinical follow-up. Importantly, the retreatment strategy in the PED group provided significantly different results vs. the coiling group (P < 0.001), with a lower recurrence rate (0.0 vs. 29.2%, respectively; P = 0.037). However, the procedural failure rate and the parent artery stenosis were more frequently in PED group compared with coiling group (both were 16.7 vs. 0.0%; P = 0.040). Conclusions: Endovascular retreatment for recurrent aneurysms after initial endovascular treatment might be safe and effective. Flow diverters might be associated with reduced risk of recanalization and an increased risk of procedural failure and mild parent artery stenosis.
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Affiliation(s)
- Wenqiang Li
- Department of Neurosurgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wei Zhu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinguo Sun
- Department of Neurosurgery, Binzhou People's Hospital, Binzhou, China
| | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yang Wang
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Kun Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Al-Schameri AR, Thakur S, Kral M, Schwartz C, Pikija S, Sherif C, Weymayr F, Richling B. Microsurgical and endovascular treatment of un-ruptured cerebral aneurysms by European hybrid neurosurgeons to balance surgical skills and medical staff management. Acta Neurochir (Wien) 2021; 163:1515-1524. [PMID: 33564907 PMCID: PMC8053657 DOI: 10.1007/s00701-021-04746-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 01/27/2021] [Indexed: 12/01/2022]
Abstract
Background In Europe, aneurysm treatment performed by dually trained neurosurgeons is extremely scarce. We provide outcome data for un-ruptured aneurysm patients treated at a European hybrid center to prove that hybrid neurosurgeons achieve clinical and angiographical results allowing to integrate hybrid neurosurgery into routine aneurysm treatment. This will not only help to maintain neurovascular microsurgical skills but will influence staff costs in related hospitals. Methods We retrospectively analyzed all consecutively treated un-ruptured aneurysm patients between 2000 and 2016. The decision-making took into account the pros and cons of both modalities and considered patient and aneurysm characteristics. Clinical outcome was assessed by the modified Rankin scale (mRS). Occlusion rates were stratified into grade I for 100%, grade II for 99–90%, and grade III for <90% occlusion. To account for the introduction of stents, two treatment periods (p1, 2000 to 2008; p2, 2009 to 2016) were defined. Results The study population consisted of 274 patients (median age 55 years) harboring 338 un-ruptured aneurysms. Microsurgery (MS) was performed in 51.8% and endovascular therapy (EVT) in 43.1%; 5.1% required combined treatment. Overall, 93% showed a favorable clinical outcome (mRS 0–2), 94.3% after MS and 91.5% after EVT. Grade I aneurysm occlusion was achieved in 82.6% patients, 91.9% after MS and 72.9% after EVT. Procedure-related complications occurred after MS in 5.6% and after EVT in 4.4% patients. Mortality was recorded for five (1.8%) patients, one patient after MS and four after EVT. For the EVT cohort, significant improvement from p1 to p2 was seen with clinical outcomes (P=0.030, RR = 0.905, CI: 0.8351–0.9802) and occlusion rates (P=0.039, RR = 0.6790, CI: 0.499–0.923). Conclusion Hybrid neurosurgeons achieve qualified clinical and angiographic results. Dual training will allow to maintain neurovascular caseloads and preserve future aneurysm treatment within neurosurgery. Furthermore economic benefits could be observed in hospital management.
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Affiliation(s)
- Abdul Rahman Al-Schameri
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria.
| | - Som Thakur
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Michael Kral
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Christoph Schwartz
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Slaven Pikija
- Department of Neurology, Paracelsus Medical University, Salzburg, Austria
| | - Camillo Sherif
- Department of Neurosurgery, Karl Landsteiner University of Health Sciences, University Hospital St. Poelten, St. Poelten, Austria
| | - Friedrich Weymayr
- Department of Neuroradiology, Paracelsus Medical University, Salzburg, Austria
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Yue J, Xie Y, Zhang X, Jiang Y, Chen W, Ma Y, Cheng Y. The safety and outcomes of acutely ruptured intracranial aneurysms with incomplete occlusion after coiling: a case-control study. BMC Neurol 2020; 20:412. [PMID: 33176706 PMCID: PMC7661196 DOI: 10.1186/s12883-020-01991-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Incomplete aneurysmal occlusion is a common feature of immediate posttreatment angiography. The safety and outcomes of acutely ruptured intracranial aneurysms (RIAs) with incomplete occlusion after stent-assisted coiling (SAC) and no-stent coiling (NSC) have not been well clarified. Progressive occlusion of stents can promote the complete occlusion of intracranial aneurysms (IAs), but it remains to be determined if progressive occlusion in acutely RIAs with incomplete occlusion after coiling may be enhanced by protective stenting. This study aimed to evaluate the safety and outcomes of those aneurysms after SAC and NSC; And to discover whether the stents can promote progressive aneurysm occlusion in such lesions or not. METHODS We reviewed 199 patients with acutely RIAs underwent endovascular coiling and developed incomplete occlusion in the past seven years. The patients' clinical and imaging information were recorded and analyzed. Univariate and multivariate analyses were performed to determine the association of recurrence rate with potential risk factors. RESULTS SAC group had wider aneurysms neck (3.471 mm vs 2.830 mm, P = 0.009) and smaller dome-to-neck ratio (1.536 vs 2.111, P = 0.001) than in NSC group. There was no significant difference between the two groups in total procedure-related complications rate (31.7% vs 23.5%, P = 0.195), procedure-related mortality (6.9% vs 2.0%, P = 0.170) and modified Rankin Scale (mRS) score at 6-month follow-up (P > 0.05). However, SAC group had significantly higher ischemic complications rate (21.8% vs 8.2%, P = 0.007) and complete occlusion rate (65.6% vs 48.3%, P = 0.020), and lower recurrence rate (15.6% vs 28.1%, P = 0.042) than NSC group based on 6-month follow-up angiograms. Additionally, Multivariable analysis showed NSC was an independent risk factor for aneurysm recurrence (Odds Ratio [OR]: 4.061; P = 0.018). CONCLUSIONS Acutely RIAs with incomplete occlusion after SAC is associated with higher complications rate and mortality, but has an acceptable safety profile and similar clinical outcome compared to NSC, as well as gives patients superior angiography outcome by progressive occlusion of stents.
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Affiliation(s)
- Jianhe Yue
- Department of Neurosurgery, Chongqing Medical University Affiliated Second Hospital, No.76 Linjiang road, Yuzhong District, Chongqing, 400010, China
| | - Yuan Xie
- Department of Neurosurgery, Chongqing Medical University Affiliated Second Hospital, No.76 Linjiang road, Yuzhong District, Chongqing, 400010, China
| | - Xiaolin Zhang
- Department of Neurosurgery, Chongqing Medical University Affiliated Second Hospital, No.76 Linjiang road, Yuzhong District, Chongqing, 400010, China
| | - Yongxiang Jiang
- Department of Neurosurgery, Chongqing Medical University Affiliated Second Hospital, No.76 Linjiang road, Yuzhong District, Chongqing, 400010, China.
| | - Weifu Chen
- Department of Neurosurgery, Chongqing Medical University Affiliated Second Hospital, No.76 Linjiang road, Yuzhong District, Chongqing, 400010, China
| | - Ying Ma
- Department of Neurosurgery, Chongqing Medical University Affiliated Second Hospital, No.76 Linjiang road, Yuzhong District, Chongqing, 400010, China
| | - Yuan Cheng
- Department of Neurosurgery, Chongqing Medical University Affiliated Second Hospital, No.76 Linjiang road, Yuzhong District, Chongqing, 400010, China
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Tian Z, Zhang M, Li G, Jin R, Leng X, Zhang Y, Wang K, Zhang Y, Yang X, Xiang J, Liu J. Hemodynamic differences by increasing low profile visualized intraluminal support (LVIS) stent local compaction across intracranial aneurysm orifice. Interv Neuroradiol 2020; 26:557-565. [PMID: 32830566 DOI: 10.1177/1591019920952903] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The Low-profile Visualized Intraluminal Support device (LVIS) has been successfully used to treat cerebral aneurysm, and the push-pull technique has been used clinically to compact the stent across aneurysm orifice. Our aim was to exhibit the hemodynamic effect of the compacted LVIS stent. METHODS Two patient-specific aneurysm models were constructed from three-dimensional angiographic images. The uniform LVIS stent, compacted LVIS and Pipeline Embolization Device (PED) with or without coil embolization were virtually deployed into aneurysm models to perform hemodynamic analysis. Intra-aneurysmal flow parameters were calculated to assess hemodynamic differences among different models. RESULTS The compacted LVIS had the highest metal coverage across the aneurysm orifice (case 1, 46.37%; case 2, 67.01%). However, the PED achieved the highest pore density (case 1, 19.56 pores/mm2; case 2, 18.07 pores/mm2). The compacted LVIS produced a much higher intra-aneurysmal flow reduction than the uniform LVIS. The PED showed a higher intra-aneurysmal flow reduction than the compacted LVIS in case 1, but the results were comparable in case 2. After stent placement, the intra-aneurysmal flow was further reduced as subsequent coil embolization. The compacted LVIS stent with coils produced a similar reduction in intra-aneurysmal flow to that of the PED. CONCLUSIONS The combined characteristics of stent metal coverage and pore density should be considered when assessing the flow diversion effects of stents. More intra-aneurysmal flow reductions could be introduced by compacted LVIS stent than the uniform one. Compared with PED, compacted LVIS stent may exhibit a flow-diverting effect comparable to that of the PED.
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Affiliation(s)
- Zhongbin Tian
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Mingqi Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Gaohui Li
- ArteryFlow Technology Co., Ltd, Hangzhou, China
| | - Rongbo Jin
- ArteryFlow Technology Co., Ltd, Hangzhou, China
| | | | - Ying Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Kun Wang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Yisen Zhang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Xinjian Yang
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | | | - Jian Liu
- Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
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Chiu AHY, Phillips TJ. Future Directions of Flow Diverter Therapy. Neurosurgery 2020; 86:S106-S116. [PMID: 31838531 PMCID: PMC6911736 DOI: 10.1093/neuros/nyz343] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 05/26/2019] [Indexed: 12/20/2022] Open
Abstract
The treatment of intracranial aneurysms has undergone a few very significant paradigm shifts in its history. Needless to say, microsurgery and surgical clipping served as the initial basis for successful treatment of these lesions. The pursuit of endovascular therapy subsequently arose from the desire to reduce the invasiveness of therapy. While the first breakthrough arose with Guido Guglielmi's invention of the detachable platinum coil, commercialized flow diverter therapy represents a disruptive therapy with a completely different paradigm for aneurysmal obliteration. This has not only altered the distribution of aneurysmal management strategies, but also opened the gateway to the treatment of previously inoperable lesions. With the basic flow diverter stent technology now considered an integral part of the neurointerventional armamentarium, we now consider what may lay in the future - including potential directions for research with regards to case selection; the location and type of aneurysms which may become routinely treatable; and modifications to the flow diverter, which may increase its utility and safety in terms of size, structural design, and surface modifications.
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Affiliation(s)
- Albert Ho Yuen Chiu
- Neurological Intervention & Imaging Service of Western Australia, Sir Charles Gairdner, Fiona Stanley and Royal Perth Hospitals, WA Health, Perth, Australia
- Division of Medicine, University of Western Australia, Perth, Australia
| | - Timothy John Phillips
- Neurological Intervention & Imaging Service of Western Australia, Sir Charles Gairdner, Fiona Stanley and Royal Perth Hospitals, WA Health, Perth, Australia
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16
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Ocal O, Peker A, Balci S, Arat A. Placement of a Stent within a Flow Diverter Improves Aneurysm Occlusion Rates. AJNR Am J Neuroradiol 2019; 40:1932-1938. [PMID: 31582390 DOI: 10.3174/ajnr.a6237] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 08/13/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Placement of a stent within a flow diverter has been described previously but its consequences have not been analyzed. We evaluated the clinical and angiographic results of stent placement within a flow diverter during the same treatment session. MATERIALS AND METHODS All patients treated with a Surpass flow diverter were retrospectively evaluated. Patients with previously deployed stents and procedures in which scaffolding stents, a second flow diverter, or intrasaccular devices were used were excluded. Patient and aneurysm characteristics and clinical and imaging follow-up results were compared between stented and nonstented Surpass flow-diverter groups and stent assisted coiling. RESULTS Thirty-five patients (41 aneurysms) were treated with a Surpass flow diverter only (monotherapy group), and in 33 patients (35 aneurysms), a stent was placed within the Surpass flow diverter (stented group). Stents were placed inside the Surpass flow diverter for a variety of reasons at the operator's discretion. No statistical difference was noted between the 2 groups in age, body weight, sex, history of thromboembolic events, smoking, platelet inhibition levels, hypertension, hyperlipidemia, diabetes mellitus, malignancy, and aneurysm location. Aneurysms in the stented group were larger than those in the monotherapy group (14.8 versus 9.1 mm, P < .001). The rate of clinically significant adverse events and complete aneurysm occlusion rates at 0-3 and 3-6 months (73.3% versus 61.3%, P = .31, and 84.8% versus 70.2%, P = .14) were similar. At 9-12 months, a significantly higher proportion of aneurysms in the stented group achieved complete occlusion (93.9% versus 73.2%, P = .019). There was a trend toward a higher obliteration rate on final follow-up in the stented group (93.9% versus 82.9%, P = .14). CONCLUSIONS Placement of a stent within a flow diverter increases the rate of aneurysm occlusion. We propose that these results are from improved flow-diverter apposition due to the higher radial force of intracranial stents.
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Affiliation(s)
- O Ocal
- From the Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - A Peker
- From the Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - S Balci
- From the Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - A Arat
- From the Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Fukuda H, Sato D, Kato Y, Tsuruta W, Katsumata M, Hosoo H, Matsumaru Y, Yamamoto T. Comparing Retreatments and Expenditures in Flow Diversion Versus Coiling for Unruptured Intracranial Aneurysm Treatment: A Retrospective Cohort Study Using a Real-World National Database. Neurosurgery 2019; 87:63-70. [DOI: 10.1093/neuros/nyz377] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 07/02/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Flow diverters (FDs) have marked the beginning of innovations in the endovascular treatment of large unruptured intracranial aneurysms, but no multi-institutional studies have been conducted on these devices from both the clinical and economic perspectives.
OBJECTIVE
To compare retreatment rates and healthcare expenditures between FDs and conventional coiling-based treatments in all eligible cases in Japan.
METHODS
We identified patients who had undergone endovascular treatments during the study period (October 2015-March 2018) from a national-level claims database. The outcome measures were retreatment rates and 1-yr total healthcare expenditures, which were compared among patients who had undergone FD, coiling, and stent-assisted coiling (SAC) treatments. The coiling and SAC groups were further categorized according to the number of coils used. Retreatment rates were analyzed using Cox proportional hazards models, and total expenditures were analyzed using multilevel mixed-effects generalized linear models.
RESULTS
The study sample comprised 512 FD patients, 1499 coiling patients, and 711 SAC patients. The coiling groups with ≥10 coils and ≥9 coils had significantly higher retreatment rates than the FD group with hazard ratios of 2.75 (1.30-5.82) and 2.52 (1.24-5.09), respectively. In addition, the coiling group with ≥10 coils and SAC group with ≥10 coils had significantly higher 1-year expenditures than the FD group with cost ratios (95% CI) of 1.30 (1.13-1.49) and 1.31 (1.15-1.50), respectively.
CONCLUSION
In this national-level study, FDs demonstrated significantly lower retreatment rates and total expenditures than conventional coiling with ≥ 9 coils.
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Affiliation(s)
- Haruhisa Fukuda
- Graduate School of Medical Sciences, School of Medicine, Kyushu University, Fukuoka, Japan
| | - Daisuke Sato
- National Institute of Public Health, Saitama, Japan
| | - Yoriko Kato
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Wataro Tsuruta
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Masahiro Katsumata
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Hisayuki Hosoo
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, School of Medicine, Yokohama City University, Kanagawa, Japan
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18
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Ye Z, Ai X, You C. Letter to the Editor. Complications from the use of flow-diverting devices. Neurosurg Focus 2019; 44:E10. [PMID: 29490549 DOI: 10.3171/2017.11.focus17694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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19
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Ocal O, Arat A. Intra-aneurysmal air after flow diversion treatment in intracranial aneurysms: incidence, characteristics and clinical significance. Jpn J Radiol 2019; 37:549-554. [PMID: 31062213 DOI: 10.1007/s11604-019-00842-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 04/27/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To describe the rate and characteristics of air bubble retention (ABR) within cerebral aneurysms treated by flow diversion. METHODS Procedural flat detector CT (FDCT) studies were scrutinized for the presence of air bubbles (density < - 200 HU) in patients treated by flow diversion. Patients with intrasaccular treatment or previous clipping were excluded. Clinical outcomes, procedural angiograms, aneurysm characteristics and imaging features of air within the aneurysm were evaluated. RESULTS Bubbles were noted in 17.1% of 105 aneurysms in 85 FDCTs. Aneurysms with ABR were significantly larger (mean diameter: 18.9 versus 7.5 mm, P < 0.0001). There was a trend for the use of multiple devices during the treatment of these aneurysms (72.2% vs 49.4%, P = 0.071). All of the bubbles were located rostrally in the aneurysm sac and were smaller than 6 mm (mean diameter: 2.1 ± 1.3 mm). None of the patients had post-procedural neurological deterioration. The air had spontaneously disappeared on follow-up CT images (available in 12 patients) obtained at a mean follow-up duration of 48 h. CONCLUSIONS ABR is not infrequent in cerebral flow diversion procedures. It is a clinically silent and self-limited technical complication. We propose air entrapment or filtration through the flow diverter as causative factors.
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Affiliation(s)
- Osman Ocal
- Department of Radiology, Faculty of Medicine, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Anıl Arat
- Department of Radiology, Faculty of Medicine, School of Medicine, Hacettepe University, Ankara, Turkey.
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20
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Enriquez-Marulanda A, Salem MM, Ascanio LC, Maragkos GA, Gupta R, Moore JM, Thomas AJ, Ogilvy CS, Alturki AY. No differences in effectiveness and safety between pipeline embolization device and stent-assisted coiling for the treatment of communicating segment internal carotid artery aneurysms. Neuroradiol J 2019; 32:344-352. [PMID: 30998116 DOI: 10.1177/1971400919845368] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Aneurysms arising from the communicating segment (C7) of the internal carotid artery (ICA) are one of the most frequent locations of intracranial aneurysms. Stent-assisted coiling (SAC) and flow diversion therapies are both endovascular strategies used for the treatment of ICA aneurysms occurring at the C7 segment. OBJECTIVE The aim of this study is to compare both methods' angiographic and functional outcomes, and procedural complications. To our knowledge, this is the first study to compare both modalities for aneurysms at this location. METHODS A retrospective review was performed of our prospectively collected database from 2008 until 2017 for patients treated with SAC and from 2013 until 2017 for patients treated with pipeline embolization devices (PEDs). RESULTS We identified 35 patients for this cohort with 38 aneurysms; 17 treated with SAC and 21 with PED. Mean age was 59 years, and 30 patients were female (86%). Complete occlusion at last follow-up occurred in 70.6% of patients in the SAC group and in 81% in the PED group (p = 0.45). Posterior communicating artery patency at last follow-up did not differ significantly between the two groups (94.1% vs 85.7%; p = 0.40). Good functional outcome at last follow-up (mRS 0-2) was achieved in 100% and 88.2% of patients, respectively. Additionally, there was no significant difference between the two groups for retreatment rates, procedural hemorrhagic, or thromboembolic complications. CONCLUSION SAC and PED are two equally efficacious modalities for endovascular treatment of ICA aneurysms arising at the communicating segment of the ICA.
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Affiliation(s)
| | - Mohamed M Salem
- 1 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Luis C Ascanio
- 1 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Georgios A Maragkos
- 1 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Raghav Gupta
- 1 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Justin M Moore
- 1 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ajith J Thomas
- 1 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Abdulrahman Y Alturki
- 1 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.,2 Department of Neurosurgery, The National Neuroscience Institute, Riyadh, Saudi Arabia
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Liu JM, Zhou Y, Li Y, Li T, Leng B, Zhang P, Liang G, Huang Q, Yang PF, Shi H, Zhang J, Wan J, He W, Liang C, Zhu G, Xu Y, Hong B, Yang X, Bai W, Tian Y, Zhang H, Li Z, Li Q, Zhao R, Fang Y, Zhao K. Parent Artery Reconstruction for Large or Giant Cerebral Aneurysms Using the Tubridge Flow Diverter: A Multicenter, Randomized, Controlled Clinical Trial (PARAT). AJNR Am J Neuroradiol 2018; 39:807-816. [PMID: 29599173 DOI: 10.3174/ajnr.a5619] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 02/26/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Although flow diverters have been reported with favorable clinical and angiographic outcomes in various literatures, randomized trials determining their true effectiveness and safety are still in lack. The Parent Artery Reconstruction for Large or Giant Cerebral Aneurysms Using the Tubridge Flow Diverter (PARAT) trial was designed to evaluate the safety and efficacy of the Tubridge flow diverter in the treatment of large or giant aneurysms in comparison with Enterprise stent-assisted coiling. MATERIALS AND METHODS This prospective, multicenter, randomized trial was conducted at 12 hospitals throughout China. Enrolled adults with unruptured large/giant intracranial aneurysms were randomly assigned (1:1) to receive either Enterprise stent-assisted coiling or Tubridge flow diverter implantation. The primary end point was complete occlusion at 6-month follow-up, while secondary end points included technical success, mortality, target vessel-related stroke, aneurysm bleeding, in-stent stenosis, parent artery occlusion, and the frequency of all adverse events. RESULTS Among 185 enrolled subjects, 41 withdrew before procedure initiation. Overall, 82 subjects underwent Tubridge implantation, and 62 subjects were primarily treated with stent-assisted coiling. The results of 6-month follow-up imaging included complete occlusion rates of 75.34% versus 24.53% for the Tubridge and stent-assisted coiling groups, respectively, with a calculated common odds ratio of 9.4 (95% confidence interval, 4.14-21.38; P < .001). There was a higher, nonsignificant frequency of complications for Tubridge subjects. Multivariate analysis showed a decreased stroke rate at the primary investigational site, with a marginal P value (P = .051). CONCLUSIONS This trial showed an obviously higher rate of large and giant aneurysm obliteration with the Tubridge FD over Enterprise stent-assisted coiling. However, this higher obliteration rate came at the cost of a nonsignificantly higher rate of complications. Investigational site comparisons suggested that a learning curve for flow-diverter implantation should be recognized and factored into trial designs.
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Affiliation(s)
- J-M Liu
- From the Department of Neurosurgery, (J.-m.L., Y.Z., P.-f.Y., B.H., Y.X., Q.L., R.Z., Y.F., K.Z., Q.H.), Shanghai Changhai Hospital, Shanghai, China
| | - Y Zhou
- From the Department of Neurosurgery, (J.-m.L., Y.Z., P.-f.Y., B.H., Y.X., Q.L., R.Z., Y.F., K.Z., Q.H.), Shanghai Changhai Hospital, Shanghai, China
| | - Y Li
- Department of Neurosurgery (Y.L., X.Y.), Tiantan Hospital, Beijing, China
| | - T Li
- Department of Interventional Radiology (T.L., W.B.), Henan Provincial People's Hospital, Henan Province, China
| | - B Leng
- Department of Neurosurgery (B.L., Y.T.), Huashan Hospital, Shanghai, China
| | - P Zhang
- Department of Neurosurgery (P.Z., H.Z.), Xuanwu Hospital, Beijing, China
| | - G Liang
- Department of Neurosurgery (G.L., Z.L.), General Hospital of Shenyang Military, Shenyang Province, China
| | - Q Huang
- From the Department of Neurosurgery, (J.-m.L., Y.Z., P.-f.Y., B.H., Y.X., Q.L., R.Z., Y.F., K.Z., Q.H.), Shanghai Changhai Hospital, Shanghai, China
| | - P-F Yang
- From the Department of Neurosurgery, (J.-m.L., Y.Z., P.-f.Y., B.H., Y.X., Q.L., R.Z., Y.F., K.Z., Q.H.), Shanghai Changhai Hospital, Shanghai, China
| | - H Shi
- Department of Neurosurgery (H.S.), First Clinical Hospital affiliated with Harbin Medical University, Heilongjiang Province, China
| | - J Zhang
- Department of Neurosurgery (J.Z.), Second Affiliated Hospital of Zhejiang University, Hangzhou Municipality, Zhejiang, China
| | - J Wan
- Department of Neurosurgery (J.W.), Renji Hospital, Shanghai, China
| | - W He
- Department of Neurosurgery (W.H.), Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - C Liang
- Department of Neurosurgery (C.L.), First Hospital of China Medical University, Shenyang Municipality, Liaoning, China
| | - G Zhu
- Department of Neurosurgery (G.Z.), Southwest Hospital, Chongqing Municipality, China
| | - Y Xu
- From the Department of Neurosurgery, (J.-m.L., Y.Z., P.-f.Y., B.H., Y.X., Q.L., R.Z., Y.F., K.Z., Q.H.), Shanghai Changhai Hospital, Shanghai, China
| | - B Hong
- From the Department of Neurosurgery, (J.-m.L., Y.Z., P.-f.Y., B.H., Y.X., Q.L., R.Z., Y.F., K.Z., Q.H.), Shanghai Changhai Hospital, Shanghai, China
| | - X Yang
- Department of Neurosurgery (Y.L., X.Y.), Tiantan Hospital, Beijing, China
| | - W Bai
- Department of Interventional Radiology (T.L., W.B.), Henan Provincial People's Hospital, Henan Province, China
| | - Y Tian
- Department of Neurosurgery (B.L., Y.T.), Huashan Hospital, Shanghai, China
| | - H Zhang
- Department of Neurosurgery (P.Z., H.Z.), Xuanwu Hospital, Beijing, China
| | - Z Li
- Department of Neurosurgery (G.L., Z.L.), General Hospital of Shenyang Military, Shenyang Province, China
| | - Q Li
- From the Department of Neurosurgery, (J.-m.L., Y.Z., P.-f.Y., B.H., Y.X., Q.L., R.Z., Y.F., K.Z., Q.H.), Shanghai Changhai Hospital, Shanghai, China
| | - R Zhao
- From the Department of Neurosurgery, (J.-m.L., Y.Z., P.-f.Y., B.H., Y.X., Q.L., R.Z., Y.F., K.Z., Q.H.), Shanghai Changhai Hospital, Shanghai, China
| | - Y Fang
- From the Department of Neurosurgery, (J.-m.L., Y.Z., P.-f.Y., B.H., Y.X., Q.L., R.Z., Y.F., K.Z., Q.H.), Shanghai Changhai Hospital, Shanghai, China
| | - K Zhao
- From the Department of Neurosurgery, (J.-m.L., Y.Z., P.-f.Y., B.H., Y.X., Q.L., R.Z., Y.F., K.Z., Q.H.), Shanghai Changhai Hospital, Shanghai, China
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22
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Zhou G, Su M, Yin YL, Li MH. Complications associated with the use of flow-diverting devices for cerebral aneurysms: a systematic review and meta-analysis. Neurosurg Focus 2017; 42:E17. [DOI: 10.3171/2017.3.focus16450] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe objective of this study was to review the literature on the use of flow-diverting devices (FDDs) to treat intracranial aneurysms (IAs) and to investigate the safety and complications related to FDD treatment for IAs by performing a meta-analysis of published studies.METHODSA systematic electronic database search was conducted using the Springer, EBSCO, PubMed, Medline, and Cochrane databases on all accessible articles published up to January 2016, with no restriction on the publication year. Abstracts, full-text manuscripts, and the reference lists of retrieved articles were analyzed. Random-effects meta-analysis was used to pool the complication rates across studies.RESULTSSixty studies were included, which involved retrospectively collected data on 3125 patients. The use of FDDs was associated with an overall complication rate of 17.0% (95% confidence interval [CI] 13.6%–20.5%) and a low mortality rate of 2.8% (95% CI 1.2%–4.4%). The neurological morbidity rate was 4.5% (95% CI 3.2%–5.8%). No significant difference in the complication or mortality rate was observed between 2 commonly used devices (the Pipeline embolization device and the Silk flow-diverter device). A significantly higher overall complication rate was found in the case of ruptured IAs than in unruptured IA (odds ratio 2.3, 95% CI 1.2–4.3).CONCLUSIONSThe use of FDDs in the treatment of IAs yielded satisfactory results with regard to complications and the mortality rate. The risk of complications should be considered when deciding on treatment with FDDs. Further studies on the mechanism underlying the occurrence of adverse events are required.
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Affiliation(s)
- Geng Zhou
- 1Department of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai
| | - Ming Su
- 2Shandong Academy of Chinese Medicine, Lixia, Jinan; and
| | - Yan-Ling Yin
- 3Department of Anesthesiology, The Military General Hospital of Beijing PLA, Beijing, China
| | - Ming-Hua Li
- 1Department of Diagnostic and Interventional Radiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai
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23
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Iosif C, Mounayer C, Yavuz K, Saleme S, Geyik S, Cekirge HS, Saatci I. Middle Cerebral Artery Bifurcation Aneurysms Treated by Extrasaccular Flow Diverters: Midterm Angiographic Evolution and Clinical Outcome. AJNR Am J Neuroradiol 2017; 38:310-316. [PMID: 27979794 DOI: 10.3174/ajnr.a5022] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 09/15/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE Flow diverters have been increasingly used lately in off-label, distal intracranial aneurysm treatments. Our aim was to evaluate the effectiveness of flow diverters in the treatment of middle cerebral artery bifurcation aneurysms and to analyze midterm angiographic patterns of regional flow modifications for safety and clinical outcomes. MATERIALS AND METHODS Consecutive patients treated from January 2010 to December 2014 by the authors by using endovascular flow-diverting stents for MCA bifurcation aneurysms were evaluated retrospectively with prospectively maintained data. All patients had been followed for at least 12 months after treatment, with at least 2 control angiograms; regional flow-related angiographic modifications were registered by using a new angiographic outcome scale for flow diverters. Data were analyzed with emphasis on procedure-related events, angiographic results, and clinical outcome. RESULTS Fifty-eight patients were included in the study, with 63 MCA bifurcation aneurysms; 13 of these were large and giant. Pretreatment mRS was 0 for 12 patients (20.7%), 1 for 41 (70.7%), and 2 for 5 patients (8.6%). Six-month control revealed mRS 0-2 for 57 (98.3%) patients and 3 for 1 (1.7%) patient. Procedure-related morbidity and mortality were 8.6% (5/58) and 0%, respectively. From 95% of still circulating immediate postprocedure angiographic outcomes, 68% progressed to aneurysm occlusion at 6 months and 95%, to occlusion at 12 months, with a 0% aneurysm rupture rate. CONCLUSIONS Flow diverters seem to be an effective treatment alternative for complex MCA bifurcation aneurysms, with reasonable complication rates. Longer angiographic follow-ups are needed to assess the morphologic outcome; immediate subtotal occlusions do not seem to be related to rupture.
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Affiliation(s)
- C Iosif
- From the Interventional Neuroradiology Department (C.I., C.M., S.S.), Dupuytren University Hospital (Centre Hospitalier Universitaire Limoges), Limoges, France
| | - C Mounayer
- From the Interventional Neuroradiology Department (C.I., C.M., S.S.), Dupuytren University Hospital (Centre Hospitalier Universitaire Limoges), Limoges, France
| | - K Yavuz
- Interventional Neuroradiology Department (K.Y.), Ankara University, School of Medicine, Ankara, Turkey
| | - S Saleme
- From the Interventional Neuroradiology Department (C.I., C.M., S.S.), Dupuytren University Hospital (Centre Hospitalier Universitaire Limoges), Limoges, France
| | - S Geyik
- Interventional Neuroradiology Department (S.G.), Memorial HealthCare Group, Istanbul, Turkey
| | - H S Cekirge
- Interventional Neuroradiology Department (H.S.C.), Koru Hospital and Bayındır Hospital, Ankara, Turkey
| | - I Saatci
- Interventional Neuroradiology Department (I.S.), Yuksek Ihtisas University, Koru Hospital, Ankara, Turkey
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Zhang X, Lv N, Wang C, Cao W, Liu J, Huang Q. Late recurrence of a completely occluded large intracranial aneurysm treated with a Tubridge flow diverter. BMJ Case Rep 2016; 2016:bcr-2016-012268. [PMID: 27329093 DOI: 10.1136/bcr-2016-012268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
We report a rare case of recurrence of a large intracavernous aneurysm after angiography proved complete occlusion. The aneurysm was treated by a combination of a Tubridge flow diverter and coils, and balloon angioplasty, after flow diverter devices deployment for parent vessel stenosis. Six month angiographic follow-up demonstrated complete occlusion. Unfortunately, obvious aneurysm recurrence was confirmed on 2 year angiographic follow-up. The probable mechanism of recurrence was analyzed.
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Affiliation(s)
- Xiaoxi Zhang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Nan Lv
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Chi Wang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Wei Cao
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Qinghai Huang
- Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China
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25
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Flow Diversion for All Middle Cerebral Artery Aneurysms-Are We There Yet? World Neurosurg 2016; 90:617-618. [PMID: 26723295 DOI: 10.1016/j.wneu.2015.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 12/16/2015] [Indexed: 11/23/2022]
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